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Information Sources for Investigation

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Article Information
Category: Safety Management Safety Management
Content source: ICAO ICAO
Content control: EUROCONTROL EUROCONTROL

Note: This article is a supplement to the article Safety Occurrence Investigation and is an extract from ICAO Doc 9859 - Safety Management Manual, Chapter 8. (First Edition).

Information Sources

Information relevant to a safety investigation can be acquired from a variety of sources, including:

a) Physical examination of the equipment used during the safety event. This may include examining the front-line equipment used, its components, and the workstations and equipment used by supporting personnel (e.g.

ATCOs, maintenance and servicing personnel).

b) Documentation spanning a broad spectrum of the operation, for example:

  1. maintenance records and logs;
  2. personal records/logbooks;
  3. certificates and licences;
  4. in-house personnel and training records and work schedules;
  5. operator’s manuals and Standard Operating Procedures (SOPs);
  6. training manuals and syllabi;
  7. manufacturers’ data and manuals;
  8. regulatory authority records;
  9. weather forecasts, records and briefing material; and
  10. flight planning documents;
  11. aeronautical information publications.

c) Recordings (flight recorders, ATC radar / flight data and voice tapes, etc.). These may

provide useful information for determining the sequence of events. In addition to traditional flight data

recordings, maintenance recorders in new generation aircraft are a potential additional source of information.

d) Interviews conducted with individuals directly or indirectly involved in the safety event. These can

provide a principal source of information for any investigation. In the absence of measurable data, interviews may

be the only source of information. More importantly, interviews are often the only way to answer the important ‘why’

question, which in turn will facilitate the establishment of appropriate and effective safety improvement

recommendations.

e) Direct observation of actions performed by operating or maintenance personnel in their work environment.

This can reveal information about potential unsafe conditions. However, the persons being observed must be aware of

the purpose of the observations.

f) Simulations. These permit reconstruction of an occurrence and can facilitate a better understanding of the

sequence of events that led up to the occurrence, and the manner in which personnel responded to the event. Computer

simulations can be used to reconstruct events using data from on-board recorders, ATC radar / flight data / voice

recordings and other physical evidence.

g) Specialist advice. Investigators cannot be experts in every field related to the operational environment.

It is important that they realize their limitations. When necessary, they must be willing to consult with other

professionals during an investigation.

h) Safety databases. Useful supporting information may come from accident/incident databases, in-house hazard

and incident reporting systems, confidential reporting programmes, systems for monitoring line operations (e.g.

flight data analysis, LOSA and Normal Operations Safety Survey (NOSS) programmes), manufacturers’ databases, etc.

Related Articles

Further Reading

ICAO